079200772-1-6-2023-15-AS-HHUL-CP5N6S-20230217091133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200772
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:35:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220303170232

FACILITY NAME:	REVITALIZE CARE HOME LLC		FACILITY NUMBER:	079200772
ADMINISTRATOR:	DACE, GENEVIEVE		FACILITY TYPE:	735
ADDRESS:	1913 CARDIFF DR		TELEPHONE:	(925) 705-8635
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 6	DATE:	01/06/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Shamari Washington-Pitre, Caregiver		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff caused injuries to resident.

INVESTIGATION FINDINGS:

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On 1/6/2023 at 10:00AM, Licensing Program Analysts (LPAs) G. Luk and L. Francisco arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPAs met with Caregiver, Shamari Washington-Pitre and informed her the reason for the visit.

During the course of investigation, LPAs interviewed 2 clients, 7 staff, and complainant. LPAs also reviewed documents including admission agreement, IPP, ISP, emergency information, incident reports, and photos of injuries. Interview with clients and staff revealed that no staff caused any bruises or injuries to clients.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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